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Wound Care Skills

What does nonpathogenic mean? Harmless, do not produce disease
What does pathogenic mean? Cause specific diseases or infections
What does asepsis mean? Absence of pathogenic microorganisms
What does medical asepsis mean? Techniques that inhibit growth and transmission of pathogenic microorganisms, clean technique
What does surgical asepsis mean? Techniques that destroy all microorganisms and their spores, sterile technique
What is a nosocomial infection? Infection acquired while in the hospital or other health care agency
What does the CDC define as "Standard precautions"? To interrupt the chain of infection & transmission of blood-borne pathogens and other potentially infectious materials
What is the best way to prevent infections in patients in the health care system? Hand hygiene
What is proper hand hygiene? Wash hands before & after pt. care, touching body fluids, secretions, excretions, and contaminated equipment; between pt. contact; and immediately after removing gloves
What is important to remember when gloving? Wear the correct size
What are the "standard precautions"? Hand hygiene, gloving, gowning, mask & protective eyewear
What is the first tier of CDC's isolation guidelines? Standard precautions
What is the second tier of CDC's isolation guidelines? Disease specific isolation; transmissions categories: airborne, droplet, & contact precautions
Which way does the label face when pouring sterile solutions? Towards palm
What is important to remember when teaching patients for infections prevention & control Both patient & families have to learn to use infection prevention & control practices at home. Need to be aware of how infection is spread & ways to prevent transmission. Educate about techniques used to control spread of infection
What physical changes in the skin do you look for when assessing patient? Color, texture, thickness, turgor, temperature, and hydration
What is impaired skin integrity? Pressure ulcers
When do pressure ulcers occur? Sufficient pressure on the skin to cause the blood vessels in an area to collapse
What are the factors that play a role in pressure ulcers? Unrelieved pressure, friction & shearing force
What is the definition of pressure ulcer? Localized injury to the skin or underlying tissue, usually over a bony prominence cause by pressure with shear or friction
How many stages are there to pressure ulcers? Four
What is Stage I of pressure ulcer? Localized area of skin intact with nonblanchable redness
What is Stage II of pressure ulcer? Partial-thickness loss of dermis
What is Stage III of pressure ulcer? Full-thickness tissue loss in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed
What is Stage IV of pressure ulcer? Involves full-thickness tissue loss with exposed bone, tendon, or muscle
What is an Unstageable/unclassified pressure ulcer? Involves full-thickness tissue loss, a wound base covered by slough (yellow, tan, gray, green, or brown) and eschar in the wound bed that usually is tan, brown, or black
What is a "suspected deep tissue injury"? Wound appears as a localized purple or maroon area of discolored intact skin or a blood-filled blister
What are nurse interventions to skin care? Assess for improvement, document size and depth of ulcer, amount and color of exudate, presence of pain, appearance of exposed tissue (press gently to check for blanching)
How many phases are there to wound healing? Four
What is the 1st stage of wound healing? Homeostasis - Termination of bleeding, begins when injury occurs
What is the 2nd stage of wound healing? Inflammatory - Initial increase in flow of blood elements and water out of the blood vessels into vascular space. Causes cardinal signs & symptoms of inflammation (redness & swelling is normal during inflammatory)
What is the 3rd stage of wound healing? Reconstruction - Collagen formation, appears as irregular, raised, purplish, immature scar. Dehiscence most frequently occurs during reconstruction
What is the 4th stage of wound healing? Maturation - Fibroblast exit the wound, wound gains strength, healed wounds rarely return to strength tissue had prior to surgery, keloids may form
What is a keloid? Overgrowth of collagenous scar tissue at the site of a wound
What holds a clot together? Fibrin
How many processes are there to wound healing? Three
What is the 1st process to wound healing? Primary intention - Wound is made surgically, skin edges are close together, minimal scarring results, process begins during the inflammatory phase of healing
What is the 2nd process to wound healing? Secondary intention - Healing occurs when skin edges are not close together or when pus has formed, wound may have purulent exudate
What is the 3rd process to wound healing? Tertiary intention-Occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together. Occurs when a contaminated would is left open & sutured closed after the infection is controlled or a primary wound becomes infected
What are the affecting factors in healing? Nutritional needs, fluids, rest & activity,
What nutrients are key to healing process? Vitamin A & C, protein & zinc
What is purulent fluid? Producing or containing pus
Do surgical wounds that are aseptically created heal slow or quick? Quick
What is a wet-to-dry dressing primary purpose? Mechanically debride a wound, the moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound & debrides it when removed
What commonly used wetting agents in a wet-to-dry- dressing? Normal saline & lactated ringers solution, acetic acid, sodium hypochlorite solution, povidone-iodine, & antibiotic solutions
Would a wet-to-dry dressing be appropriate for a pressure ulcer? Yes
What are transparent dressings? Self-adhesive film that is synthetic permeable membrane that acts a temporary secondary skin
What is the best way to avoid fluid retention when irrigating a wound? Position patient on his/her side to encourage flow of the irrigant away from the wound
What is the purpose of irrigation? Promote wound healing through the removal of debris from a wound surface decreasing bacterial counts, and loosening & removing eschar
What is the proper way to irrigate a wound? Least contaminated to most contaminated
Why do you irrigate wound least contaminated to most contaminated? Prevent cross contamination
What may bleeding in a wound indicate? Slipped suture, dislodged clot, coagulation problem, or trauma to blood vessels or tissue
What is an indication of internal bleeding? Dressing may be dry while abdominal cavity collects blood. HR will be increased, BP will be decreased & urinary output will be decreased
Define Dehiscence (Dehiss)? Wound layer separate, pt. may say "something has given way", it may result after periods of coughing, sneezing, or vomiting, may be preceded by serosanguineous drainage
What are nursing interventions for Dehiss? Pt. should remain in bed & be NPO, be told not to cough, and be reassured. Place warm, moist sterile dressing over the area until provider evaluates the site
Define Evisceration? Abdominal organs protrude through an opened incision
What are nursing interventions for evisceration? Pt. is to remain in bed, and the wound & contents should be covered w/warm, sterile, saline dressings. Surgeon should be notified immediately (this is medical emergency, & wound requires surgical repair)
When does the CDC label a wound as "infected"? It contains purulent drainage
What will a patient with an infected wound present with? Fever, tenderness, and pain @ the wound site; edema and an elevated WBC
Describe purulent drainage? Odor, brown, yellow or green, depending on the pathogen
Define exudate Fluid, cells or others substances that have slowly exuded from cells or blood vessels through small pores or breaks in the cell membrane
Define drainage Removal of fluids from a body cavity, wound or other source of discharge through one or more methods
Define serous Clear, watery plasma
Define sanguineous Bright red; indicates active bleeding
Define serosanguineous Pale, red, watery; mixture of serous & sanguineous
What do you assess when checking drainage? Color, amount, consistency & odor
What is a T-Tube? Drainage tube frequently inserted into the duct to maintain a free flow of bile, it exits through the abdominal incision or a separate surgical wound, it drains via gravity into a closed drainage system (bag is emptied & measured every shift)
What does wound vac mean? Vacuum - assisted closure device
What is a wound vac? Negative-pressure wound therapy
What is the Jackson-Pratt drain? Closed drainage system that uses a bulb to provide the needed vacuum
What is an open drainage system? Rubber/plastic used to remove exudate from the wound and deposit it out through the skin onto a dressing
What is the Penrose drain? Sterile safety pin placed through the drain to keep it from sliding into the wound
What is a Hemovac? Table vacuum container that is an expandable unit connected by tubes to the drainage site
What are the nursing interventions after a bandage is applied? Assess, document & immediately report changes in circulation, skin integrity comfort level, and body function such as ventilation or movement
What is a closed wound? Underlying tissue of the body is involved; top layer of skin is not broken
What are nursing interventions for closed wound? Small - ice packs & elastic bandage; Large - treat for shock, cold compresses & pressure bandage
What is a open wound? Openings or breaks in the mucous membrane or skin; they are always in danger of bleeding or infection
What are types of open wounds? Abrasions, punctures, incisions, lacerations, avulsions & chest injuries
What is ablative surgery? Excision or removal of diseased body part (amputation, removal of appendix, cholecystectomy
What are influencing factors for the older patient in surgery? Recovers more slowly, increased risk of aspiration, atelectasis, pneumonia, thrombus formation, infection, & altered tissue perfusion (pressure ulcer), increased risk for disorientation & toxic reactions, teaching time may be prolonged
What are the 6 steps to controlled coughing? Take several deep breaths, Inhale through nose, Exhale though mouth w/ pursed lips, Inhale deeply again & hold breath for count of three, Cough two or three consecutive times w/out inhaling, caution against clearing throat
What do leg exercises prevent? Venostasis
What is a pneumatic compression device? SCD - Sequential Compression Device
What are antiembolism stockings called? Ted hose
What is the best is the best way to prevent venostasis & sluggish bowels? Ambulation
How long do you need to listen for bowel sounds before you can notate that bowel sounds are absent? 3 mins/quadrant
What is the role of the circulating nurse? Prepares necessary equipment, arranges sterile & non-sterile supplies, performs appropriate assessments, counts sponges, needles, and equipment after surgery, observes for break in sterile technique
What is the order of thorough assessment when a patient goes to PACU? Airway, Breathing, LOC, Circulation, System assessment
When can you give patient pain meds? If they are PRN, when they ask for them
What are signs/symptoms for shock? Tachycardia, restlessness, pale, moist skin, weak & thready pulse, cyanotic skin
What is a sign/symptom for pulmonary embolism? SOB/Chest pain
What is the 1st sign of hemorrhage? Restlessness
When do you do incision assessments? Every 2-4 hours
What do you assess for incision assessments? Bleeding, color, exudate, temperature, drainage, wound edges, monitor for evisceration
What is objective data when assessing for pain? Increased pulse rate, restlessness, moaning, guarding
What is subjective data when assessing for pain? Patient reports pain, pain scale assessment, OPQRST
Is addiction an issue for regular surgery? No
What do you assess for venostasis? Strength of pedal pulses, edema in legs, aching legs, redness in legs, skin color, skin temperature
What should discharge instructions include? Wound care guidelines, medications, activities, when to call the doctor, when to follow up
Created by: tandkhopkins
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